Unformatted text preview: [ FORM 23 —Use the top of this page for your letterhead.] Consent to Use and Disclose Your Health Information This form is an agreement between you, and me/us, . When we use the words “you” and “your” below, this can mean you, your child, a relative, or some other person if you have written his or her name here: . When we examine, test, diagnose, treat, or refer you, we will be collecting what the law calls “protected health informa- tion” (PHI) about you. We need to use this information in our office to decide on what treatment is best for you and to provide treatment to you. We may also share this information with others to arrange payment for your treatment, to help carry out certain business or government functions, or to help provide other treatment to you. By signing this form, you are also agreeing to let us use your PHI and to send it to others for the purposes described above. Your signature below acknowledges that you have read or heard our notice of privacy practices, which explainsabove....
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- Spring '10
- representative, Sign, personal representative, Privacy Practices